Overview
Definition:
ERAS (Enhanced Recovery After Surgery) deviations refer to instances where the established protocol for perioperative patient care is not followed or is modified significantly
These deviations can occur due to patient-specific factors, unforeseen intraoperative events, or system-level issues
Proper identification and management of deviations are crucial for maintaining the benefits of ERAS pathways and ensuring optimal patient outcomes.
Epidemiology:
The incidence of ERAS deviations varies widely depending on the institution, surgical specialty, and the specific ERAS pathway
Studies report deviation rates from 10% to over 50% in some pathways, with common deviations including inadequate carbohydrate loading, delayed mobilization, and suboptimal pain management
Factors contributing to deviations include staff compliance, patient understanding, and resource availability.
Clinical Significance:
ERAS pathways are evidence-based multimodal protocols designed to accelerate recovery, reduce length of hospital stay, and improve patient satisfaction after surgery
Deviations from these protocols can negate the intended benefits, leading to increased morbidity, longer recovery times, higher costs, and potentially worse patient outcomes
Therefore, understanding and troubleshooting deviations is paramount for effective surgical practice and successful examination preparation.
Common Deviations
Preoperative Deviations:
Failure to administer pre-operative carbohydrate loading
Inadequate pre-operative hydration
Missed or delayed pre-operative antibiotic prophylaxis
Poor patient education regarding the ERAS protocol
Non-adherence to pre-operative bowel preparation where indicated.
Intraoperative Deviations:
Prolonged duration of surgery beyond expected limits
Excessive fluid administration or restriction
Use of contraindicated anesthetic agents or techniques
Inadequate intra-operative analgesia
Failure to adhere to intra-operative warming protocols.
Postoperative Deviations:
Delayed initiation of oral intake
Failure to mobilize patients early (e.g., within 24 hours)
Suboptimal pain management leading to patient discomfort or inability to mobilize
Delayed removal of drains or catheters
Absence of post-discharge follow-up as per protocol
Use of opioids when non-opioid analgesics could be sufficient.
Troubleshooting Approach
Identification And Reporting:
Establishing a clear system for identifying and reporting deviations
This may involve pre-defined checklists, direct observation, or feedback mechanisms from the multidisciplinary team
Timely reporting allows for prompt intervention.
Root Cause Analysis:
Investigating the underlying reasons for the deviation
This can involve patient-related factors (e.g., comorbidities, non-compliance), staff-related factors (e.g., lack of training, workload), system-related factors (e.g., inadequate resources, communication breakdowns), or protocol-related factors (e.g., ambiguity, inflexibility).
Multidisciplinary Team Discussion:
Engaging the entire surgical team (surgeons, anesthesiologists, nurses, physiotherapists, dietitians) to discuss deviations
Collaborative problem-solving is essential to identify effective solutions and prevent recurrence.
Protocol Modification And Education:
Based on identified patterns of deviation, consider if the ERAS protocol needs minor adjustments for specific patient groups or scenarios
Equally important is ongoing education and re-education of the multidisciplinary team on protocol adherence and the rationale behind each component.
Managing Specific Deviations
Delayed Oral Intake:
Assess for ileus or anastomotic leak
If no signs of complication, re-attempt clear fluids as tolerated
Consider prokinetic agents if appropriate
Encourage early ambulation to promote gut motility.
Inadequate Pain Control:
Review pain assessment tool and administer scheduled analgesia as per protocol
Consider escalating to multimodal analgesia with judicious use of opioids
Address psychological factors contributing to pain perception
Ensure adequate post-operative physiotherapy.
Delayed Mobilization:
Identify barriers to mobilization (e.g., pain, fear, fatigue, insufficient staffing)
Provide enhanced pain relief
Ensure physiotherapy is readily available and patients are motivated
Consider adjunctive therapies like incentive spirometry.
Opioid Overuse:
Strictly adhere to multimodal analgesia guidelines
Educate patients and staff on the risks of opioids
Implement opioid-sparing strategies
Consider opioid rotation or dose reduction when appropriate, and monitor for withdrawal symptoms.
Prevention Strategies
Standardization And Simplification:
Ensure ERAS protocols are clearly written, concise, and easily accessible to all team members
Standardized order sets and electronic health record alerts can help.
Education And Training:
Regular training sessions for all members of the multidisciplinary team on ERAS principles and specific pathway components
Highlight the importance of each step and the consequences of deviations.
Performance Monitoring And Feedback:
Implement systems to track ERAS compliance and identify deviations
Provide regular feedback to the team on their performance and areas for improvement
Audit adherence to the protocol.
Patient Engagement:
Empower patients with knowledge about the ERAS protocol through pre-operative education materials and discussions
Patient buy-in and understanding can significantly improve adherence.
Team Communication:
Foster a culture of open communication where team members feel comfortable raising concerns or questioning deviations
Regular multidisciplinary meetings are crucial for sharing information and addressing challenges.
Key Points
Exam Focus:
ERAS deviations are frequently tested
Be prepared to identify common deviations, their causes, and evidence-based management strategies
Understanding the multidisciplinary nature of ERAS is key
Recall the specific components of ERAS pathways relevant to common surgical procedures.
Clinical Pearls:
The most effective way to manage deviations is to prevent them through robust education and standardized processes
Always consider patient-specific factors when evaluating adherence
Celebrate successes and learn from failures without blame.
Common Mistakes:
Focusing solely on the surgeon's role in deviations, neglecting the contributions of other team members
Failing to conduct a thorough root cause analysis, leading to recurring issues
Implementing rigid protocols without flexibility for necessary clinical adaptations
Underestimating the importance of patient education in adherence.